Journal Club

Psychological treatment of generalized anxiety

disorder: A meta-analysis

ERICA WILLSON
NELLIE L AWLOR
RILEY GRAHAM
What is Generalized Anxiety
Disorder?
Generalized
anxiety disorder
or (GAD) is a
highly
prevalent,
chronic, costly
and disabling
mental disorder.
 Background Research
GAD was first introduced in the DSM in 1980

Other types of therapies for GAD

psychodynamic therapies non-directive supportive
therapy (Stanley, Beck, & DeWitt Glassco, 1996)
Spiritual therapy (Koszycki, Raab, Aldosary, &
Bradwejn, 2010)
 Aim and Purpose
1. Examine whether it could assess the overall effects of
psychotherapies for GAD.
2. Assess whether there are now enough studies to evaluate the long-
term effects of GAD treatments.
3. To examine whether enough studies are now available to compare
the differential effects between types of therapy.
4. Examine the quality of psychotherapy studies.
5. Since recent trials tend to meet quality criteria more often, it also
examined the association between publication year and the
outcome.
Significance of the article

1. Large number of trials used in the meta analysis

2. Results more accurate/generalizable
Main Findings
Comparisons
Cognitive Behavioural Therapy (CBT) VS Applied Relaxation:
Compared in 5 studies
Effect size revealed comparable difference between the two
Statistical power too small to justify further analysis

CBT VS Pharmacotherapy:
Compared in 4 studies
Small, non-significant result favoured CBT
Main Findings
Long term Outcomes
Psychotherapy VS Control:
3 studies
Follow up periods; 3-15 months
Odds Ratio for a positive outcome = 1.53; Indicates Psychotherapy may produce
better results than control
Statistical power too small to continue analysis
CBT VS Applied Relaxation:
5 studies
Follow up periods; 6-24 months
No significant difference between the methods at 6 months and 24 months
CBT showed significantly better results at 12 months
Main Findings
Internet Based Treatment VS Face-to-face treatment
Small amount of studies on Internet-based treatment
Despite this, the effect size revealed the treatments yield comparable results
Findings consistent to previous literature (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010)

Effects of different types of therapy and pharmacotherapy:

Number of studies too small to determine significant differences

Quality Criteria and Effect size

Recent studies has better quality criteria, however there was no evidence that they had a
higher or lower effect size than older studies
May be due to older studies meeting quality criteria without reporting it
May be due to limited amount of studies making it difficult to find significant association
Main Findings
Moderator analysis
Found Psychological treatments that met all the criteria had a smaller effect size
than those that didn't
Psychotherapy was not found to be more effect for younger people than older, as
was seen in a previous meta-analysis (Covin et al., 2008)
Findings and Conclusions
Psychological treatment of GAD may be as effective as medication
A large effect size for the treatment of depressive symptoms was found
Evidence suggest GAD often precedes depression (Schoevers, Deeg, van Tilburg, &
Beekman, 2005)
thus treatment for GAD may also reduce depressive symptoms
Clinician ratings of effects were often higher than self-report
The exact cause for this is unknown
May be due to positive bias from the clinician or negative bias from the participant
Finding consistent with other research (Cuijpers, Li, Hofmann, & Andersson, 2010).
The amount of studies directly comparing CBT and Applied relaxation was too small
Previous research has found the two methods had comparable effects (Siev & Chambless,
2007).
The number of studies was too limited in this analysis leading to unsubstantial results.
Critiquing
Time to look into whether the
Meta-analysis was conducted
in a validated way

Are conclusions justified??

Limitations
1. CBT over-focus?
- 28 x CBT, 3 x behavioural, 3x relaxation, 4 x other therapies
2. Need more follow-ups!
- 3/41 included follow-up measures
3. Too general?
- No dismantling of actual treatment types
4. Predominantly waiting list groups
- 31 involved WL groups
5. Lack of studies (& therefore lack of evidence)
- Can show effectively but not comparatively speaking
Strengths
1. Two independent raters (2= better than 1!)
- Decisions may be questioned
2. Criteria selectivity
- Narrowed down to 41/100+
3. Meta-analysis= bias avoidance
- Not own studies, objective viewpoint maintained
4. Identified LT effects as important
5. Standardised diagnosis across studies
- Validity check
Strengths cont
6. Acknowledgment & assessment of depression (common co-occurrence with GAD)

7. Clinical Psychology R/V

- Highly respected, will only use quality & peer-reviewed articles
8. Primary & secondary sources used assessed with Risk of Bias tool (Cochrane)
9. New forms of treatment included (not just traditional)
- Internet CBT
10. Subject pool
- Drawn from community, clinical & specialised mental health care environments
11. Consistency with past research findings
Overall Does indicate effectiveness of receiving clinical treatment, particularly
CBT= provides further support (no harm done!)
Implications and future research

Psychotherapy is an effective and clinically relevant form of treatment for

GAD
Lack of research about some topics
Internet based treatments
Applied relaxation
Quality criteria and outcome

Breakdown of components within the psychotherapies to reveal what is actually

effective
Implications and future research
Included studies are believed to have some limitations such as
1. Small number of studies using other than waiting list control groups,
2. The lack of follow-up measurements
3. The low quality of many of the included studies

Future research should include well established trials in order to produce

greater accuracy and less bias.
References
Andrews,G.,Cuijpers,P.,Craske,M.G.,McEvoy,P.,&Titov,N.(2010).ComputerTherapy
fortheAnxietyandDepressiveDisordersIsEffective,AcceptableandPracticalHealthCare:A
Meta-Analysis.PLoS ONE,5(10),e13196.doi:10.1371/journal.pone.0013196
Covin,R.,Ouimet,A.J.,Seeds,P.M.,&Dozois,D.J.(2008).Ameta-analysisofCBTfor
pathologicalworryamongclientswithGAD.Journal of Anxiety Disorders,22(1),108-116.
doi:10.1016/j.janxdis.2007.01.002
Cuijpers,P.,Li,J.,Hofmann,S.G.,&Andersson,G.(2010).Self-reportedversusclinician-
ratedsymptomsofdepressionasoutcomemeasuresinpsychotherapyresearchondepression:
Ameta-analysis.Clinical Psychology Review,30(6),768-778.doi:10.1016/j.cpr.2010.06.001
Cuijpers,P., Sijbrandij,M., Koole,S., Huibers,M., Berking,M., & Andersson,G.
(2014). Psychological treatment of generalized anxiety disorder: A meta-
analysis.Clinical Psychology Review,34(2), 130-140.
doi:10.1016/j.cpr.2014.01.002
Schoevers,R.A.,Deeg,D.,VanTilburg,W.,&Beekman,A.(2005).DepressionandGeneralized
AnxietyDisorder:Co-OccurrenceandLongitudinalPatternsinElderlyPatients.The American
Journal of Geriatric Psychiatry,13(1),31-39.doi:10.1097/00019442-200501000-00006
Siev,J.,&Chambless,D.L.(2007).Specificityoftreatmenteffects:Cognitivetherapyandrelaxationfor
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522.doi:10.1037/0022-006x.75.4.513
Stanley,M.A.,Beck,J.G.,&DeWittGlassco,J.(1996).Treatmentofgeneralisedanxietyinolderadults:
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Koszycki,D.,Raab,K.,Aldosary,F.,&Bradwejn,J.(2010).Amultifaithspirituallybasedintervention
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